Sultan Qaboos University Med J, August 2015, Vol. 15, Iss. 3, pp. e415–419, Epub. 24 Aug 15. doi: 10.18295/squmj.2015.15.03.018. Submitted 14 Dec 14 Revision Req. 26 Jan 15; Revision Recd. 16 Feb 15 Accepted 24 Mar 15 Although there are approximately 60 published reports on chromosome 7p duplication, the de novo duplication of the short arm of chromosome 7—without involving any rearrangements with other chromosomes in the form of unbalanced translocations—is extremely rare.1–3 The size of the duplicated segment varies from patient to patient.2,3 The phenotype spectrum also varies accordingly, but its association with a clinical manifestation of autism spectrum disorder (ASD) is rarely documented. Wolpert et al. reported a duplication of the 7p11.2p14 region in a 25-year-old male patient with autism.4 The current report presents an autistic child with unique features and duplication of chromosome 7p21.1p22.2. To the best of the authors’ knowledge, this is the first report of a patient with 7p duplication associated with ASD involving region 7p21.1. Case Report A three-year-old male child presented to the Sultan Qaboos University Hospital in Muscat, Oman, in January 2012. He was diagnosed with global developmental delay, hypotonia and abnormal repetitive social interactions. He was the first child born to a healthy Omani consanguineous couple (first cousins); the mother was 24 years old and the father was 25 years old. The child had a birth weight of 2.11 kg. 1Department of Genetics, College of Medicine & Health Sciences, Sultan Qaboos University; Departments of 2Child Health and 3Genetics, Sultan Qaboos University Hospital, Muscat, Oman *Corresponding Author e-mail: uday.achandira@gmail.com وجود طفرة جينية للتضاعف الصبغي يف 7p21.1p22.2 يف طفل لديه اضطراب طيف التوحد واختالفات خلقية اأت�ساديرا موثابا أوداياكومار، وطفة املعمرية، عبري ال�سائغ، عديلة الكندية abstract: The duplication of the short arm of chromosome 7 as de novo is extremely rare. The phenotype spect- rum varies depending on the region of duplication. We report a case of de novo duplication of chromosomal region 7p21.1p22.2 in a three-year-old male child with autism who presented to the Sultan Qaboos University Hospital in Muscat, Oman, in January 2012. The patient was diagnosed with craniofacial dysmorphism, global developmental delay, hypotonia and bilateral cryptorchidism. The duplication was detected by conventional G-banded karyotype analysis/fluorescence in situ hybridisation and confirmed by array comparative genomic hybridisation. To the best of the authors’ knowledge, this is the first report of chromosomal region 7p21.1 involvement in an autistic patient showing features of a 7p duplication phenotype. Identifying genes in the duplicated region using molecular techniques is recommended to promote characterisation of the phenotype and associated condition. It may also reveal the possible role of these genes in autism spectrum disorder. Keywords: Autism Spectrum Disorder; Array Comparative Genomic Hybridization; Craniofacial Abnormalities; Chromosome 7; Duplication 7p; Case Report; Oman. امللخ�ص: يعد الت�ساعف ال�سبغي للذراع الأق�رس لكرومو�سوم 7 حالة نادرة جداً. ويعتمد النمط الظاهري للحالة على املنطقة املت�ساعفة للكرومو�سوم. ونعر�س يف هذا البحث وجود ت�ساعف �سبغي يف الذراع الأق�رس للكرومو�سوم 7 يف املنطقة 7p21.1p22.2 يف طفل قد مت ت�سخي�سه با�سطراب طيف التوحد يف م�ست�سفى جامعة ال�سلطان قابو�س يف يناير 2012م. وي�سمل النمط الظاهري للحالة الآتي: اختالفات خلقية يف الوجه، وتاأخر منائي عام، وارتخاء يف الع�سالت واختالف خلقي يف اخل�سيتني. ومت ت�سخي�س هذا الختالف ال�سبغي عن طريق درا�سة النمط الكرومو�سومي ومت تاأكيده بتقنية امليكرو اأريه. ومبلغ علمنا تعترب هذه احلالة هي الأوىل التي توؤ�رس إىل وجود ارتباط بني الختالفات ال�سبغية يف 7p21.1 وت�سخي�س ا�سطراب طيف التوحد. ن�ستنتج من هذه احلالة وجود جينات يف املنطقة ال�سبغية 7p مرتبطة با�سطراب طيف التوحد و حتث على عمل درا�سة دقيقة للجينات املوجودة يف هذه املنطقة ال�سبغية ودرا�سة مدى اأهميتها لفهم الأ�سباب اجلينية ملر�س ا�سطراب طيف التوحد. مفتاح الكلمات: ا�سطراب طيف التوحد؛ ميكرو اري؛ اختالفات خلقية يف الوجه؛ كرومو�سوم 7؛ الت�ساعف ال�سبغي يف 7p؛ تقرير احلالة؛ عمان. De Novo Duplication of 7p21.1p22.2 in a Child with Autism Spectrum Disorder and Craniofacial Dysmorphism *Achandira M. Udayakumar,1 Watfa Al-Mamari,2 Abeer Al-Sayegh,3 Adila Al-Kindy3 online case report De Novo Duplication of 7p21.1p22.2 in a Child with Autism Spectrum Disorder and Craniofacial Dysmorphism e416 | SQU Medical Journal, August 2015, Volume 15, Issue 3 Upon examination, the patient would not speak spontaneously and rarely vocalised directly to either the examiners or his parents. Non-verbal communicat- ions (including gestures, smiling, pointing or using other body parts) and the range of distinct facial expressions were very limited. Methods of communication were not coordinated with eye contact and the child showed limited enjoyment during interactions. The patient did not request objects and was not interested in showing objects to others. He showed no interest in symbolic/pretend play but demonstrated unusual sensory interest in materials (e.g. licking objects). The patient showed stereotypical motor repetitive behaviour (repetitive hand flicking) and persistent odd hand positioning in the form of bilateral wrist flexion. No disruptive, aggressive or self-injurious behaviours were noted. His communication and reciprocal social interaction scores fell within the range of ASD. Based on the above clinical and multidisciplinary evaluations, the patient was diagnosed with ASD. The patient had delayed developmental milestones, demonstrating head control at the age of 12 months old, sitting with support by 14 months old, standing with support by two years old and walking by the time he was three years old. His hearing test results were normal, although an eye examination showed hypermetropic astigmatism. During a follow-up ophthalmological appointment, a slightly enlarged cup-to-disc ratio was noticed, indicating glaucoma. Features of craniofacial dysmorphism were observed, including a high forehead with a prominent metopic ridge; brachycephalic and plagiocephalic closed anterior fontanelle; a low v-shaped posterior hairline; well-arched thin eyebrows; hypoplastic alae naris; narrow anteverted nares; a bulbous nasal tip; ears with prominent crus and overfolded helices; a short philtrum; a prominent lower lip; micrognathia; and bilateral cryptorchidism. The patient had undergone an operation for the cryptorchidism. The coronal sutures were open but appeared narrow. The height and weight of the patient were both at the 50–75th centile, with head circumference at the 25th centile. Magnetic resonance imaging of the brain, echocardiography and abdominal ultrasonography findings were unremarkable. The parents refused permission for photographs of the child to be published. Peripheral blood chromosomal G-band karyo- typing analysis was performed with 400–550 band resolution, which showed a 46, XY, dir dup(7) (p21p22) karyotype [Figure 1A]. Fluorescence in situ hybridisation using a subtelomeric probe (Cytocell Ltd., Cambridge, UK) showed the presence of telomeres on both short arms of chromosome 7 [Figure 1B]. The parental karyotypes were normal, indicating the 7q duplication in the child to be a de novo occurrence. Array-based comparative genomic hybridisation (aCGH) using 8x60k oligoarray platforms (Oxford Gene Technology, Begbroke, Oxfordshire, UK) confirmed the presence of a cytogenetically visible duplication within the short arm of one chromosome 7. Analysis using CytoSure™ Interpret software, Version 3.4.8 (Oxford Gene Technology), showed that this duplication was ~16.5 million bases (Mb) in size. The breakpoints were also refined. The duplication involving the region 7p22.2 to 7p21.1 thus showed arr 7p22.2p21.1(2,811,886-19,358,897)x3, with a minimum size of ~16.5 Mb and a maximum size of ~16.7 Mb Figure 1A & B: A: Partial karyotype showing the G-banded pairs of chromosome 7 and the duplicated segment 7p21-22 (arrows) in an autistic child with craniofacial dysmorphism. B: Fluorescence in situ hybridisation showing telomeres (arrows) on the 7p region. Figure 2: Array comparative genomic hybridisation of an autistic child with craniofacial dysmorphism showing a duplication interval of ~16.5 million bases within the breakpoints at chromosome 7p22.2 and 7p21. Achandira M. Udayakumar, Watfa Al-Mamari, Abeer Al-Sayegh and Adila Al-Kindy Online Case Report | e417 of 7p in a few cases or smaller terminal 7p segments in others.2 Arens et al. reported complete 7p trisomy (without the involvement of any other chromosomes) in two patients.6 Similar diagnoses have been made in five other patients.4,7 Many phenotypic features common to 7p duplication syndrome were present in the patient in the current report [Table1];1,4,10,11 these have also been described in earlier case reports.3,6,8 Notably, the patient described in the current report did not have any cardiovascular abnormalities and thus had a better prognosis compared to patients in previous reports who died early as a result of these abnormalities.3,6,8 Evidence suggests that most 7p duplications occur due to malsegregation of parental balanced translocations or abnormal recombination of parental chromosome inversions and that these duplications rarely result from de novo partial 7p direct [Figure 2]. This analysis was done commercially. No other imbalances were detected. The duplication interval contained 67 annotated genes, of which six had morbid entries in the Online Mendelian Inheritance in Man® (OMIM) catalogue. However, the genes in this region were not directly disrupted by the breakpoints. Discussion Duplication of 7p has been reported previously and the region/size varies among patients.1–13 Common features include craniofacial anomalies, a large fontanelle, dysmorphism and psychomotor delay, with hypotonia being the most common complication observed.1–8,10,11,13 In their review of the literature, Cai et al. found that 50% of 7p duplications were the result of balanced reciprocal translocation carriers.3 Reish et al. suggested that these could be an entire duplication Table 1: Comparative analysis of cases of de novo 7p duplication in the literature Characteristic/clinical finding Author and year of case report Wolpert et al.4 2001 Papadopoulou et al.1 2006 Zahed et al.11 2007 Chui et al.10 2011 Present case Region 7p11.2p14.1 7p13p22.1 7p22.1p22.3 7p22.1 7p21.1p22.2 Size N/A N/A 5 Mb 1.7 Mb 16.5 Mb Confirmatory test WCP FISH Multicolour FISH Array CGH Array CGH Array CGH Origin De novo De novo De novo De novo De novo Karyotype 46.XY,?dup(7) (p14.1p11.2) 46,XX,dup(7).ish.dup(7) (p-ter>p13::p22.1>qter) 46,XY,add(7) (p22).arr cgh 7p22.3p22.1x3 46,XY.ish. subtle (41x2) .arr7p22.1x3 46,XY,dup(7) (p21p22). arr7p22.2p21.2x3 Patient age/gender 25 years/male 9 months/female 1.6 years/male 2.4 years/male 3 years/male Nationality or ethnicity Caucasian Greek Lebanese Peruvian Omani Dysmorphism No Yes Yes Yes Yes Developmental delay No Yes N/A Yes Yes Consanguineous parents N/A No Yes No Yes Hypotonia N/A No Yes No Yes High forehead Yes N/A N/A Yes Yes Low nasal bridge Yes N/A N/A Yes Yes Low-set ears N/A N/A Yes Yes No Cardiovascular abnormalities Yes N/A N/A Yes No Abnormal palmar creases No N/A N/A Yes No Skeletal anomalies No N/A N/A No No Autism spectrum disorder Yes No No No Yes Cryptorchidism No No Bilateral Yes Bilateral Ocular hypertelorism No N/A No Yes Yes N/A = not available; WCP = whole chromosome painting ; FISH = fluorescence in situ hybridisation; CGH = comparative genomic hybridisation. De Novo Duplication of 7p21.1p22.2 in a Child with Autism Spectrum Disorder and Craniofacial Dysmorphism e418 | SQU Medical Journal, August 2015, Volume 15, Issue 3 duplication.2,3 The critical region for physical and mental abnormalities is 7p15-pter;2 for craniofacial dysmorphism, it is 7p21.2,3,9 Both these patient groups, viz. those with physical and mental abnormalities, have many specific features in common. The range of severity may depend on the size and genes involved. Research has suggested that the glioma-associated oncogene family zinc finger 3 (OMIM entry *165240; 7p13), homeobox A13 (OMIM entry *142959; 7p15-7p14.2), twist family basic helix-loop-helix transcription factor 1 (TWIST1; OMIM entry *601622; 7p21), craniosynostosis type 1 (OMIM entry 123100; 7p21.3-7p21.2) and mesenchyme homeobox 2 (OMIM entry *600535; 7p22.1-7p21.3) genes are associated with phenotypic 7p syndromes.1 Chui et al. reported a patient with microduplication at 7p22.1 (1.7 Mb) who showed all of the common craniofacial features and had cryptorchidism, but did not have global developmental delay or hypotonia.10 Although the region 7p22.1 contains 27 genes, 13 of which are OMIM-annotated, only one gene (β-actin [ACTB]; OMIM entry *102630; 7p22.1) was commonly observed in both Chui et al.’s patient and the patient in the current report.10 This would mean that ACTB is likely to be the causative factor for features like hypotonia, global developmental delay and cryptorchidism in the current patient. The segmental size of the duplication in the current patient was larger than those reported elsewhere.10,11 Furthermore, there was an association with ASD. Notably, two reports have associated 7p duplication with this disorder.4,12 Wolpert et al. described an inverted duplication of 7p14.1p11.2 in an autistic adult, who lacked many of the characteristic features found in 7p duplication syndrome.4 This may indicate that the critical region was distal. The patient was normocephalic, had normal developmental milestones, meatal stenosis, bilateral esotropia and mild scoliosis.4 Cukier et al. reported a pair of autistic first cousins carrying two microduplications, one of whom had a tandem duplication on 7p21 replicating part of the neurexophilin 1 (NXPH1; OMIM entry *604639) and islet cell autoantigen 1 (ICA1; OMIM entry *147625) genes.12 The patient in the current report was a child with direct duplication, clinical features of microcephaly and delayed milestones. None of the other features reported by Cukier et al. were present in the current patient.12 However, both patients had common autistic phenotypes and behavioural features.12 The duplication was more proximal in Cukier et al.’s case,12 whereas it was distal in the current patient. It has been suggested that the region within the duplication interval (7p21.1 to 7p22.2) observed in the current patient is the critical region for manifestations of the 7p duplication phenotype.13 This region of 7p contains the OMIM morbid gene TWIST1, duplications of which are thought to be the cause of the large fontanelles in these patients;13 it is hence likely to be the cause of the current patient’s clinical phenotype. The duplication region of this patient encompassed the whole of the TWIST1, ICA1 and NXPH1 genes. These genes, however, were not directly disrupted by the breakpoints of the duplication. The aCGH analysis could not determine whether this duplication might have a position effect on the regulation of these genes. Parental chromosomal studies confirmed that the duplication in the presently reported patient was de novo and did not occur from a balanced chromosomal rearrangement, which may sometimes occur as insertional translocations.14 These translocations underlie 2.1% of apparently observed de novo interstitial copy number changes detected by aCGH.14 Further molecular analysis is worth considering for genes of the duplicated region, particularly when they are associated with ASD phenotypes, for further delineation of genotype-phenotype correlations. Conclusion A de novo duplication of chromosomal region 7p21.1p- 22.2 was identified in a three-year-old autistic child with craniofacial dysmorphism, global developmental delay, hypotonia and bilateral cryptorchidism. Characterising the genes involved in duplication regions may help in understanding the genotype-phenotype correlation in 7p duplication patients. It may also reveal the possible role of these genes in ASD. aCGH analysis is an important tool in revealing genetic abnormalities among children with intellectual disabilities and dysmorphic features, as these are usually not detected by conventional cytogenetics. References 1. Papadopoulou E, Sifakis S, Sarri C, Gyftodimou J, Liehr T, Mrasek K, et al. A report of pure 7p duplication syndrome and review of literature. Am J Med Genet A 2006; 140:2802–6. doi: 10.1002/ajmg.a.31538. 2. Reish O, Berry SA, Dewald G, King RA. Duplication of 7p. Further delineation of the phenotype and restriction of the critical region to the distal part of the short arm. Am J Med Genet 1996; 61:21–5. doi: 10.1002/(SICI)1096- 8628(19960102)61:1<21::AID-AJMG4>3.0.CO;2-#. 3. Cai T, Yu P, Tagle DA, Xia J. 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